Bipolar Disorders Lecture Notes PDF

Chapter 26 Bipolar Disorders: Nursing Care of Persons with Mood Lablility NURSN6302 Isper Crissey PhD, RN Key Terms  Mania: an abnormally and persistently  Elevated mood: euphoria or elation  Expansive mood: lack of restraints in expression; overvalued self-importance...

Chapter 26 Bipolar Disorders: Nursing Care of Persons with Mood Lablility NURSN6302 Isper Crissey PhD, RN Key Terms  Mania: an abnormally and persistently  Elevated mood: euphoria or elation  Expansive mood: lack of restraints in expression; overvalued self-importance  Irritable mood: easily annoyed and provoked to anger  Manic episode: distinct period of mania  Mood lability: rapid shifts in mood with little or no change in external events Bipolar disorders Mania or hypomania alternating with depression  Bipolar I  Bipolar II  Cyclothymic disorder Bipolar 1 versus Bipolar 2  Bipolar I (major depressive, manic, or mixed episode)  Manic-depressive disorder with mood swings alternating from depressed to manic  Mania: a distinct period (of at least 1 week or less if hospitalized) of abnormally and persistently elevated, expansive, or irritable mood with abnormally increased goal-directed behavior or energy  Bipolar II  Manic-depressive disorder with mood swings alternating from depressed to hypomania BIPOLAR DISORDER 4 Bipolar 1  Most severe bipolar disorder, a progressive condition  Shifts in mood, energy, and ability to function.  Symptoms can be unpredictable and variable can lead to severe functional impairment (hospitalization, job loss, divorce, indebtedness).  Periods of normal functioning may alternate with periods of illness (highs, lows, or a combination of both).  At least one manic episode  Psychosis - experience hallucinations, delusions, and dramatically disturbed thoughts. Auditory hallucinations – voice of God. BIPOLAR DISORDER 5 DSM-5 Criteria for Bipolar I Disorder Category 1 Category 2 Category 3 Category 4 Item 1 4.5 2.3 1.7 5 Item 2 3.2 5.1 4.4 3 Item 3 2.1 1.7 2.5 2.8 Item 4 4.5 2.2 1.7 7 BIPOLAR DISORDER 6 Bipolar I Disorder Across the Life-Span  Children and adolescents  Depression usually occurring first; marked by intense rage  Symptoms reflective of developmental level of the child  Older adults  Greater neurologic abnormalities and cognitive disturbances  Incidence of mania decreased with age BIPOLAR DISORDER 7 Bipolar 2  At least one hypomanic episode and at least one major depressive episode.  Hypomania of bipolar II disorder tends to be euphoric and often increases functioning.  Psychosis is never present with hypomania but maybe present in the depressive side of BP BIPOLAR DISORDER 8 Depressive Episode  A depressive episode is serious  Clinically significant distress or impairment in social, occupational, or other important areas of functioning  For at least two weeks, the individual has suffered a depressed mood; this can manifest as pervasive sadness or irritability.  Alternately or in addition, the patient may suffer a loss of interest or pleasure in nearly all activities.  The episode cannot be better accounted for by Bereavement, the effects of a substance (a medication or drug of abuse) or a general medical condition. BIPOLAR DISORDER 9 Cyclothymic disorder  Hypomania  depressive episodes not meeting full criteria for major depressive episode  Symptoms are disturbing enough to cause social and occupational impairment.  Adults - irritable hypomanic episodes not danger to self  Children - irritability and sleep disturbance BIPOLAR DISORDER 10 Continuum of bipolar symptoms BIPOLAR DISORDER 11 Mixed Episode (specifier in DSM 5)  Thecriteria for a MDE and a ME are met nearly every day for at least a week  Again,there is marked impairment with regard to work, school, relationships, etc.---or patient needs to be hospitalized---or there are psychotic features A general medical condition or substance is not the cause of the episode BIPOLAR DISORDER 12 Bipolar Mood Cycles BIPOLAR DISORDER 13 Case Study A patient was just admitted to your unit with bipolar disorder I and is in the manic state.  What symptoms might you expect to see? BIPOLAR DISORDER 14 Case Study Discussion  Extreme drive and energy  Inflated sense of self-importance  Drastically reduced sleep requirements  Excessive talking combined with pressured speech  Personal feeling of racing thoughts  Distraction by environmental events  Unusually obsessed with and overfocused on goals  Purposeless arousal and movement  Dangerous activities, such as indiscriminate spending, reckless sexual encounters, or risky investments BIPOLAR DISORDER 15 Epidemiology and Risk Factors  Lifetime prevalence: 1% to 4%  Symptom onset: ages 14 to 21; fewer cases after 40  No gender differences in incidence  Female patients at greater risk for depression and rapid cycling than male patients  Male patients at greater risk for manic episodes  Ethnicity and culture links require additional study  Common comorbid conditions: anxiety disorders (most prevalent: panic disorder and social phobia) and substance use BIPOLAR DISORDER 16 Women and Bipolar Disorder o Women who experience a severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder. o Giving birth may act as a trigger for the first symptoms of bipolar disorder. o The precipitant may be hormonal changes and sleep deprivation. BIPOLAR DISORDER 17 Comorbidity Bipolar I Disorder - anxiety disorders (75%), attention-deficit/hyperactivity disorder and all the disruptive, impulse-control, or conduct disorders. Substance use disorder (50%) in an attempt to self medicate increases risk for suicide due to substance abuse. Bipolar II Disorder - anxiety disorders, Eating disorders (binge eating) Substance use disorder. Cyclothymic Disorder - Substance use disorder, Sleep disorders, Attention-deficit/hyperactivity disorder in children. BIPOLAR DISORDER 18 Etiology  Biologic theories  Chronobiologic theories  Genetic factors  Chronic stress, inflammation, and kindling  Psychological and social theories  Focus on reducing environmental stress and trauma in genetically vulnerable individuals BIPOLAR DISORDER 19 Etiology  Chronobiological Theory:  Sleep disturbances is a prominent feature of both mania and depression. Studies have shown that sleep deprivation can induce mania in some bipolar pts. It is speculated this occurs b/c a # of neurotransmitters and hormone levels follow circadian patterns and sleep disruption may precipitate biochemical changes that affect mood BIPOLAR DISORDER 20 Etiology  Genetic  Strong genetic component as evidenced by twin, family and adoption studies. A study by NIMH found that 25% of relatives of pts with bipolar disorder had a bipolar or MDD. Identical twins have 60-80% concordance rates for bipolar disorder  Norepinephrine, dopamine, serotonin have been studied since the 1960s as causative factors in mania and depression. There is thought to be excesses of norepinephrine and dopamine neurotransmitters during the manic phase. Its has also been suggested that the s/s of mania result from an inability to modulate neuronal excitation BIPOLAR DISORDER 21 Etiology  Sensitization and Kindling Theory:  This theory has been used to explain why, in seizure disorders, seizures can manifest with decreasing amounts of electrical or chemical stimulation. Applying the same logic to affective disorders may explain why affective episodes, esp. in bipolar disorder, recur in shorter cycles with longer duration and with less relation to environmental precipitants. This theory, if true, would explain the value of using antiseizure meds for bipolar disorder. BIPOLAR DISORDER 22 Environmental factors  Children who have a genetic and biological risk of developing bipolar disorder are most vulnerable in bad environments.  Stressfulfamily life and adverse life events may result in a more severe course of illness.  Stress is a common trigger for mania and depression in adults. BIPOLAR DISORDER 23 Case: Christine 3/1/20XX SAMPLE FOOTER TEXT 24 Video Links Manic state Homeland https://www.youtube.com/watch?v=UdbRmI9tRnE https://www.youtube.com/watch?v=LVfUYl5v4FM Psychiatric interview of a manic patient https://www.youtube.com/watch?v=zA-fqvC02oM Kay Jamison interview https://www.youtube.com/watch?v=LhzbAzSPWQ4  Living with bipolar illness https://www.youtube.com/watch?v=Rp5SeMrivRA Kay Jamison presentation The Unquiet Mind https://www.youtube.com/watch?v=eAC6jC4giu0 BIPOLAR DISORDER 25 The Nursing Process BIPOLAR DISORDER 26 Evidence-Based Nursing Care of Persons with Bipolar Disorder  Mental Health Nursing Assessment  Physical Health  Changes in activity, eating, and sleep patterns  Diet and body weight  Laboratory testing: thyroid function  Changes in sexual practices  Pharmacologic assessment  Previous use of antidepressants  Discontinuation of mood stabilizers BIPOLAR DISORDER 27 Psychological Nursing Assessment  Mental Status and Appearance  Mood  Cognition  Thought disturbances  Behavioral responses  Stress and coping  Social network and support systems  Risk assessment  Social and occupational functioning  Quality of life  Strength assessment BIPOLAR DISORDER 28 Assessment Individuals with bipolar disorder tend to spend more time in a depressed state than in a manic state  Mood  Behavior  Thought processes and speech patterns  Flight of ideas  Clang associations  Grandiosity  Cognitive functioning BIPOLAR DISORDER 29 Assessment  Mood - expansive mood which is an elevated and unrestrained emotional expressiveness.  Euphoria period – characterized by intense feelings of well-being, being “cheerful in a beautiful world,” or is becoming “one with God.” BIPOLAR DISORDER 30 Patient’s Description  At first when I’m high, it’s tremendous…ideas are fast…like shooting stars you follow until brighter ones appear…all shyness disappears, the right words and gestures are suddenly there. Uninteresting people, things become intensely interesting.  Sensuality is pervasive; the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria…you can do anything…but somewhere this changes…  The fast ideas become too fast and there are far too many…overwhelming confusion replaces clarity…you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened.  Everything now is against the grain…you are irritable, angry, frightened, uncontrollable, and trapped in the blackest caves of the mind, caves you never knew were there.  It will never end.  Madness carves its own reality. BIPOLAR DISORDER 31 Assessment Behavior  Hypomania - voracious appetites for social engagement, spending, and activity, even indiscriminate sex.  Constant activity - reduced need for sleep prevent proper rest, inadequate nutrition and dehydration.  Poor sleep - short periods of sleep, may not sleep for several days in a row.  Nonstop physical activity and the lack of sleep and food can lead to physical exhaustion and worsening  Mania BIPOLAR DISORDER 32 Assessment Thought processes and speech patterns  Flight of ideas - continuous flow of accelerated speech with abrupt changes from topic to topic. Speech is usually based on understandable associations or plays on word  Clang associations - stringing together of words because of their rhyming sounds, without regard to their meaning: “Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.”  Grandiose delusions - highly inflated self-regard. Observed in both the ideas expressed and the person’s behavior. BIPOLAR DISORDER 33 DESCRIBING MOOD & AFFECT MOOD AFFECT Anxious Restless, tensed, fearful Dysphoric Restricted/constricted, blunted, flat, tearful Euthymic Full range, appropriate Euphoric Inappropriate, excited Elated Inappropriate, excited Expansive Inappropriate, labile Irritable/Annoyed Distracted, restless, frustrated 3/1/20XX SAMPLE FOOTER TEXT 34 Case Study (Cont.)  Whatare some problems that can be avoided if your manic patient gets proper treatment? BIPOLAR DISORDER 35 Case Study (Cont.)  Suicide attempts/homicidal behavior  Alcohol or substance abuse  Marital or work problems  Development of medical comorbidity (sleep deprivation, inadequate nutrition) BIPOLAR DISORDER 36 Self-Assessment  Manic patient  Manipulative  Demanding  Splitting  Staff member actions  Frequent staff meetings to deal with patient behavior and staff response  Set limits consistently BIPOLAR DISORDER 37 Assessment Guidelines Bipolar Disorder  Danger to self or others  Need for protection from uninhibited behaviors  Need for hospitalization  Medical status  Coexisting medical conditions  Family’s understanding BIPOLAR DISORDER 38 Nursing Diagnosis  Risk for injury  Risk for violence  Other-directed  Self-directed  Ineffective coping  Imbalance nutrition less than body requirements  Sleep problems  Alteration in mood  Disturbed thought process BIPOLAR DISORDER 39 Therapeutic Relationship  Both interesting and exhausting  Provide refocusing  Remain calm and avoid power struggles  Avoid confrontations  Respect personal space  Meet with client “where they are”  Vital to preventing relapse BIPOLAR DISORDER 40 Mental Health Nursing Interventions  Recovery and Wellness Goals  Periods of stable mental health are perfect times to focus on:  Stress reduction  Illness management  Relapse prevention  Physical Care  Rest  Adequate hydration and nutrition  Reestablishment of physical well-being  Wellness challenges BIPOLAR DISORDER 41 Medication Interventions #1  Goals:rapid control of symptoms and prevention of future episodes or, at least, reduction in their severity and frequency  Mood stabilizers  Antipsychotics  Antianxiety BIPOLAR DISORDER 42 Medication Interventions #2  Mood stabilizers  Lithium (Eskalith)  Antiepileptic’s/Anticonvulsants  Divalproex sodium (Depakote)  Carbamazepine (Tegretol)  Lamotrigine (Lamictal)  Oxcarbazepine (Trileptal)  Gabapentin (Neurontin)  Topiramate (Topamax) BIPOLAR DISORDER 43 Medication Interventions #3 Antianxiety Drugs  Clonazepam (Klonopin)  Lorazepam (Ativan) Antipsychotic Drugs  Olanzapine (Zyprexa)  Risperidone (Risperdal) BIPOLAR DISORDER 44 Other Medications Used  Antidepressants  Depressive phases  Can trigger mania  Antipsychotics  Psychosis  Mania  Dosage usually lower  Benzodiazepines  Short-term for agitation BIPOLAR DISORDER 45 Medication Interventions  Lithium carbonate  Indications  Therapeutic and toxic levels  Therapeutic blood level: 0.8 to 1.5 mEq/L for acute treatment  Maintenance blood level: 0.6 to 1.2 mEq/L for chronic therapy  Toxic blood level: 1.5 mEq/L and above  Maintenance therapy  Contraindications  Major long-term risks of lithium therapy are hypothyroidism and impairment of the kidneys’ ability to concentrate urine. BIPOLAR DISORDER 46 MEDICATION MANAGEMENT: LITHIUM Lithium carbonate  Side effects - weight gain, tremor, ataxia, memory problems.  Lithium has a very narrow therapeutic level - 6 to 1.5 mEq/L below 0.6 is subtherapeutic, above 1.5 is toxic.  Symptoms of lithium toxicity - fatigue, GI upset, impaired memory, agitation, confusion, ataxia, coarse tremors, dysarthria, renal dsfx, cardiovascular changes, muscular fasciculations, myoclonus, tonic-clonic (twitching) seizures, coma, DEATH BIPOLAR DISORDER 47 LITHIUM ADVERSE EFFECTS BIPOLAR DISORDER 48 MEDICATION MANAGEMENT: LITHIUM  Monitor labs: lithium level, TSH and renal function tests Q 6 months  Major long-term risks of lithium therapy - hypothyroidism and impairment of the kidney’s ability to concentrate urine.  Avoid lithium in pts with renal or thyroid disease. Should not be used in pregnancy or if a woman is breast feeding.  Teach pts to not increase or decrease salt intake b/c lithium is a salt and there is an inverse relationship btn sodium and lithium in the body---higher the sodium levels the lower the lithium levels and vice versa. BIPOLAR DISORDER 49 Lithium Interactions BIPOLAR DISORDER 50 Interventions for Lithium Side Effects BIPOLAR DISORDER 51 Audience Response Questions What action should the nurse take on learning that a manic client’s serum lithium level is 1.8 mEq/L?  A. Withhold medication and notify the physician.  B. Continue to administer medication as ordered.  C. Advise the client to limit fluids for 12 hours.  D. Advise the client to curtail salt intake for 24 hours BIPOLAR DISORDER 52 ANSWER Answer – A  Withhold medication and notify the physician. The client’s lithium level has exceeded desirable limits. Additional doses of the medication should be withheld and the physician notified. None of the other options are accurate interventions. BIPOLAR DISORDER 53 MEDICATION MANAGEMENT Divalproex Sodium (Depakote) considered just as effective as lithium (side effx: sedation, tremor, weight gain, pancreatitis)  Obtain labs prior to initiating tx: LFTs due to possible hepatotoxicity, CBC for platelet counts due to risk of thrombocytopenia Carbamazepine (Tegretol) may be effective for pts w/ poor lithium response. (side effx: sedation, dizziness)  Obtain baseline LFTs and CBC due to possible bone marrow suppression and liver inflammation  Rare side effect: agranulocytosis or Stevens-Johnson rash/syndrome (life threatening skin reaction w/ 5% mortality) those of Asian descent esp. susceptible Lamotrigine (Lamictal): newer anticonvulsant, effective for rapid cycling and depressed phases of bipolar disorder. (SE: dizziness, sedation)  does not require blood monitoring—an advantage to pts  Black Box Warning: Stevens-Johnson rash/syndrome (life threatening skin reaction w/ 5% mortality) BIPOLAR DISORDER 54 Carbamazepine drug Interactions BIPOLAR DISORDER 55 Stevens-Johnson syndrome  Erythema multiforme major  Fever and Flu Like symptoms  Facial swelling  Tongue swelling  Hives  Be raised or discolored  Skin pain  A red or purple skin rash that spreads within hours to days  Blisters on your skin and the mucous membranes of mouth, nose, eyes and genitals  Shedding of skin BIPOLAR DISORDER 56 Medication Interventions  Administrating and Monitoring  Side effects  Complications  Promoting Adherence  Teaching Points BIPOLAR DISORDER 57 Audience Response Questions  Which anticonvulsant medication might be prescribed for a patient with bipolar disorder? a. divalproex sodium (Depakote) b. clonazepam (Klonopin) c. olanzapine (Zyprexa) d. lithium (Lithobid) BIPOLAR DISORDER 58 Answer  Answer: a Divalproex sodium (Depakote)  Of the options provided, only divalproex sodium is an anticonvulsant. Review the classifications of the distracters. BIPOLAR DISORDER 59 Other Treatments  Electroconvulsive therapy  Transcranial magnetic stimulation BIPOLAR DISORDER 60 Psychosocial Nursing Interventions  Therapeutic Interactions  Enhancing Cognitive and Behavioral Functioning  Individual cognitive–behavioral therapy  Individual interpersonal therapy  Adjunctive therapies  Psychoeducation  Teaching Strategies  Teaching About Symptoms SBIPOLAR DISORDER 61 Psychosocial Nursing Interventions  Wellness strategies  Social skills training  Providing Family Education  Promoting Safety  Implementing Milieu Therapy  Support Groups  Developing Recovery-Oriented Rehabilitation Strategies  Evaluation and Treatment Outcomes BIPOLAR DISORDER 62 Continuum of Care  Efforts to Reduce Hospitalization  Emergency care  Inpatient-focused care  Intensive outpatient programs  Community care  Virtual mental health care  Integration with Primary Care BIPOLAR DISORDER 63